Ethics Advice for Health Care Administrators

You’ve just been appointed chief of surgery, and the nursing director of the operating room comes to you and says that a surgeon is running two operating rooms simultaneously—sometimes three. On occasion, a fellow is actually performing the surgery. The nursing director is worried that patients might not have been properly informed or cared for.

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This fictional scenario was one of several considered by a panel of medical administrators. Panelists stressed the need for administrators to use patience and tact, but also firmness when necessary, in dealing with delicate circumstances involving potentially unethical behavior by surgeons.

In the case of overlapping surgeries, a discussion presented by moderator Gerald Healy, MD, past president of the Triological Society and the American College of Surgeons, panelists acknowledged that the practice is hardly uncommon but tended to agree that patient consent was the most important issue.

Michael Stewart, MD, chairman of otolaryngology at Weill Cornell Medical College in New York City, said it is important to obtain input from all sides before coming to any conclusions about a specific case; however, if the scenario were true, your first step should be to look to your own policies to see whether there have been any violations, and you might consider implementing policies if none exist.

No physician, no matter how senior, should be above the rules. “The rules and standards still have to apply, and it’s your job to implement those,” he said. Taking the step of suspending a physician might be drastic, given the long-lasting career effects, but that concern has to be balanced against the risk of patient harm.

Kenneth Grundfast, MD, chief of otolaryngology-head and neck surgery at Boston Medical Center, said that a good safety history is no excuse for not acting appropriately. “Because you haven’t had any complications doesn’t mean tomorrow there’s not going to be a horrible complication,” he added.

Educational considerations also require balance, said Carol Bradford, MD, chair of otolaryngology-head and neck surgery at the University of Michigan in Ann Arbor. “It’s not clear to me that the fellow is learning in the absence of any supervision,” she said. “I do think supervision in education requires an interaction in the operating room.”

Nevertheless, some autonomy is probably important, she added. “I’m not endorsing ethical violations to the patients and families, but I do worry about the consequence of never acting independently as a trainee and then suddenly, on day one in practice, you’re alone.” The best philosophy might be a “graduated autonomy and appropriate supervision,” she said.